Tensionable knotless anchors and methods of tissue repair

ABSTRACT

Surgical devices and methods of soft tissue repair using pre-looped tensionable and non-pre-looped tensionable knotless fixation devices. A flexible material (for example, suture or suture tape) may be attached to the fixation device. A flexible material may be threaded through an eyelet of a tip provided as part of a swivel anchor assembly to provide added stability to the fixation devices.

RELATED APPLICATION

This is a divisional of U.S. application Ser. No. 15/352,246, filed on Nov. 15, 2016, which is a continuation-in-part of U.S. application Ser. No. 15/004,154, filed on Jan. 22, 2016, now U.S. Pat. No. 10,172,606, the subject matter of which are herein incorporated by reference in their entireties.

BACKGROUND

The present disclosure relates to surgical devices and methods and, more particularly, to surgical devices and methods for use in tissue repair.

SUMMARY

Surgical assemblies, systems and techniques for knotless soft tissue repair and fixation, such as fixation of soft tissue (ligament, tendon, graft, etc.) to bone, are disclosed. Surgical assemblies comprise tensionable knotless fixation devices that are inserted into bone. A tensionable knotless fixation device is provided with a tensioning construct (formed of a tensioning strand, a tensionable, adjustable, knotless, self-cinching loop, and a splice adjacent the loop) pre-loaded onto a fixation device. A flexible material (for example, suture or suture tape) may be attached to a fixation device. A flexible material may be threaded through an eyelet of a fixation device.

Methods of soft tissue repair which do not require tying of knots and allow adjustment of both tension of suture and location of tissue with respect to bone are also disclosed.

An exemplary method includes the steps of providing a first fixation device preloaded with a tensionable construct; providing a second fixation device with a non-pre-looped tensionable construct; anchoring the first and second fixation devices in bone such that the first and second fixation devices are arranged in a medial row; passing the pre-loaded tensionable construct of the first fixation device and the non-pre-looped tensionable construct of the second fixation device through tissue; threading a free end of a flexible strand of the non-pre-looped tensionable construct through a tensionable loop of the pre-looped tensionable construct and then subsequently passing the free end of the non-pre-looped tensionable construct through an eyelet of a passing device coupled with the flexible strand of the non-pre-looped tensionable construct; and pulling on a tail end of the passing device to thread the free end of the flexible strand of the first fixation device through a splice in itself, thereby forming two interlocking loops outside of the tissue. This exemplary method may also include the steps of preloading the first and second fixation devices with first and second flexible materials, respectively; passing first and second limbs of the first and second flexible materials through the tissue proximal to the pre-looped tensionable and non-pre-looped tensionable constructs; tightening or tensioning the two interlocking loops by pulling on a free end of the pre-looped tensionable construct and the free end of the non-pre-looped tensionable construct; and securing the first and second ends of the first and second flexible material to bone with additional fixation devices.

Other objects, advantages and salient features of the invention will become apparent from the following detailed description, which, taken in conjunction with the annexed drawings, discloses preferred embodiments of the present invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1 and 2 illustrate an exemplary embodiment of a fixation device loaded onto a driver.

FIGS. 3 and 4 illustrate an exemplary embodiment of an anchor tip loaded with a tensioning construct.

FIGS. 5-8 illustrate an exemplary embodiment of an anchor tip.

FIGS. 9-11 illustrate another exemplary embodiment of an anchor tip (a 3.5 mm round eyelet).

FIGS. 12-14 illustrate another exemplary embodiment of an anchor tip (a 4 mm round eyelet).

FIGS. 15-18 illustrate another exemplary embodiment of an anchor tip (an elongated open eyelet, curved).

FIGS. 19A-19D illustrate an exemplary embodiment of a surgical assembly.

FIGS. 20-30 illustrate an exemplary method of tissue repair with the fixation device of FIG. 1.

FIGS. 31A-B illustrate pre-looped and non-pre-looped tensionable fixation devices in accordance with an exemplary embodiment of the present invention.

FIGS. 32A-32D illustrate exemplary method of tissue repair using the fixation devices of FIGS. 31A-31B.

FIGS. 33A-33C illustrate another exemplary method of tissue repair using the fixation devices of FIGS. 31A-31B.

FIGS. 34A and 34B illustrate a further exemplary method of tissue repair with the tensionable fixation device of FIGS. 31A-31B.

FIG. 35 illustrates a driver and anchor assembly.

FIGS. 36A and 36B illustrates a pre-looped tensionable loop assembly and a non-pre-looped tensionable loop assembly, respectively.

FIGS. 37A and 37B, and FIGS. 37C and 37D, illustrate an anchor construct as a pre-looped tensionable loop construct, depicted after the anchor has been inserted into the bone, and an anchor construct that is non-pre-looped tensionable loop construct, depicted after the anchor has been inserted into the bone, respectively.

DETAILED DESCRIPTION

Surgical assemblies, systems and techniques for knotless soft tissue repair and fixation, such as fixation of soft tissue (ligament, tendon, graft, etc.) to bone, are disclosed. Surgical assemblies comprise tensionable knotless fixation devices that are inserted into bone. Tensionable knotless fixation devices are provided with a tensioning construct (formed of a tensioning strand, a tensionable, adjustable, knotless self-cinching loop, and a splice adjacent the loop) pre-loaded onto the fixation device. A flexible material (for example, suture or suture tape) may be attached to the fixation device, for example, by being threaded through an eyelet of the fixation device.

As detailed below, the surgical assemblies and devices disclosed allow for knotless fixation of tissue using an eyelet suture of a fixation device (for example, a suture anchor with an eyelet or a SwiveLock® anchor). A mechanism inside the suture eyelet is similar to the knotless tensionable construct of the SutureTak®, except that there is no post or similar device within the anchor body to allow suture to wrap around. The knotless tensionable construct passes the anchor body of modified SwiveLock® anchors. In this manner, the surgical assemblies and devices detailed below combine two technologies to provide a strong knotless repair, as well as a backup knotless repair separate from a first repair.

Methods of soft tissue repair which do not require tying of knots and allow adjustment of both the tension of the suture and the location of the tissue with respect to the bone are also disclosed.

A surgical assembly can include (i) a fixation device; (ii) a tensionable construct pre-loaded on the fixation device; and (iii) a flexible material (for example, suture or suture tape) attached to the fixation device. A flexible material may be also pre-loaded on the fixation device, and may be releasably attached to the fixation device, or securely fixed to it. The fixation device can include an anchor body insertable over an anchor tip, the anchor tip including a shaft attached to an anchor tip body, the anchor tip body being provided with first and second apertures or openings (for example, an eyelet oriented in a first direction and a through-hole or passage oriented in a second direction, which may be different from the first direction). A tensionable construct may be pre-loaded on the fixation device. The tensionable construct may consist of a flexible strand with a knot and a free end, a splice and an adjustable, tensionable, self-cinching, knotless, closed loop having an adjustable perimeter, located adjacent the splice. The tensionable construct passes through the anchor tip and extends through at least a portion of the anchor body of the fixation device.

The fixation device may be a SwiveLock® anchor as disclosed and described, for example, in U.S. Pat. No. 8,012,174 issued Sep. 6, 2011, U.S. Pat. No. 9,005,246 issued Apr. 14, 2015, and US 2013/0296936 published Nov. 7, 2013, the disclosures of all of which are fully incorporated by reference in their entirety herein, with or without a modified eyelet in the anchor tip, and as detailed below.

The flexible material (suture construct) can be any suture strand or suture tape, for example, Arthrex FiberTape®, which is a high strength suture tape that is braided and rectangular-like in cross section and as disclosed in U.S. Pat. No. 7,892,256, the disclosure of which is incorporated by reference in its entirety herein. However, the fixation devices detailed below can be used with any type of flexible material or suture known in the art.

The tensionable construct may use a mechanism similar to that of knotless SutureTak® but provides variations and improvements in the design of the tensioning construct. Details of the formation of an exemplary tensioning construct employed in the embodiments of the present invention detailed below are set forth in U.S. Pat. No. 9,107,653 issued Aug. 18, 2015; US 2013/0165972, entitled “Tensionable Knotless Anchor Systems and Methods of Tissue Repair;” and US 2013/0345750, entitled “Tensionable Knotless Labral Anchor and Methods of Tissue Repair,” the disclosures of all of which are incorporated by reference in their entirety herein.

The tensionable construct may be formed of a flexible strand or flexible material that is easily spliced through itself to form a splice and a knotless, self-cinching, adjustable, closed loop with an adjustable perimeter. The flexible strand or material may be made of any known suture material, such as ultrahigh molecular weight poly ethylene (UHMWPE) or FiberWire® suture (disclosed in U.S. Pat. No. 6,716,234 the disclosure of which is herein incorporated by reference in its entirety), and can be braided or multi-filament. For example, the suture can be UHWMPE suture without a core to permit ease of splicing.

FIG. 1 illustrates an exemplary embodiment of a fixation device 10 (tensionable knotless fixation device 10) seated on a driver 91. Tensionable knotless fixation device 10 comprises an anchor body 20 and an anchor tip 30, the anchor body 20 being insertable over the anchor tip 30. A tensionable construct 50 (also referred to as “tensioning construct 50”) and a flexible material 70 are pre-loaded on the fixation device 10 to form surgical assembly 1. Tensionable knotless fixation device 10 is seated on driver 91. Driver 91 has a thin cannulated rod 92, where anchor tip 30 is seated at the proximal end 94 of the thin cannulated rod 92. Anchor body 20 is cannulated and is fully seated around thin cannulated rod 92.

Tensionable construct 50 is pre-loaded onto the fixation device 10, and extends through at least a portion of the fixation device. Flexible material 70 may be also pre-loaded onto the fixation device 10.

Anchor tip 30 includes anchor tip body 31 attached to a cannulated shaft 36 (not shown in FIG. 1), wherein the cannulated shaft 36 is at least partially disposed within thin cannulated rod 92 of driver 91. Anchor tip body 31 is also provided with first and second through-holes, openings, or passages 32, 34. In an exemplary embodiment, one of the first and second through-holes, openings, or passages is an eyelet 32 having a first orientation relative to a longitudinal axis of the anchor tip, and the other of the first and second-through holes, openings, or passages is a flexible material hole or passage 34 (a transverse opening 34) having a second orientation relative to a longitudinal axis of the anchor tip. In an exemplary embodiment, the first orientation is different from the second orientation. In another exemplary embodiment, the first orientation is about perpendicular to the second orientation. Eyelet 32 accommodates and houses tensionable construct 50. Hole, opening, or passage 34 accommodates and houses flexible material 70.

FIG. 2 illustrates another view of tensionable knotless fixation device 10 pre-loaded with tensionable construct 50 but without flexible material 70.

During installation of fixation device 10, anchor body 20 is assembled onto the operational end of the driver 91. Anchor tip 30 is threaded or otherwise attached onto the tip of thin cannulated rod 92. Anchor tip 30 is then placed within a prepared bone hole or tunnel until anchor tip 30 reaches the bottom of the bone hole or tunnel, or reaches the desired depth. At this point, anchor body 20 is still outside of the bone hole or tunnel. Anchor body 20 is then reduced down thin cannulated rod 92 (advanced down the cannulated rod to be insertable over the anchor tip 30) by holding a thumb pad (not pictured) as the inserter handle (not pictured) of the driver 91 is turned clockwise. When anchor body 20 is fully seated, cannulated shaft 36 of anchor tip 30 is fully engaged by cannulated anchor body 20, creating a stable swivel construct of the fixation device 10 wherein anchor tip 30 is rotatably secured to anchor body 20.

In an exemplary embodiment, anchor body 20 is cannulated and has a proximal end 22 and a distal end 24, wherein proximal end 22 is the end closest to anchor tip 30. The exterior 26 of anchor body 20 can be threaded, for example like a screw, or can be any suitable means for securing in a bone hole or tunnel, for example, in the form of circumferential ridges extending radially. The exterior 26 of anchor body 20 is responsible for both securing fixation device 10 in the bone hole or tunnel, as well as securing, by friction or interference fit, suture construct 70 against the bone wall and exterior 26 of anchor body 20.

Anchor body 20 (in the form of a cannulated fixation device 20 or cannulated screw 20) may be pre-loaded onto the shaft of the driver. The anchor tip 30 (implant 30) is designed to be releasably attached (by a snap fit, for example) to a distal end of the driver and to swivel relative to the anchor body 20 (cannulated fixation device 20). The anchor tip (implant) with attached suture is anchored into bone by rotating the driver to rotate and advance the anchor body 20 (cannulated fixation device 20) while keeping the anchor tip 30 (implant 30) stationary, thereby securing the suture and providing tissue fixation without tying knots in the suture. The driver with the cannulated rod (passing slidably and rotatably through a cannulated driver assembly of the driver) has a tip adapted to accept the anchor tip 30 (implant 30), to allow the anchor tip 30 to be loaded onto the rod and be fully seated on an end of the shaft of the driver.

The anchor tip 30 (implant 30) is rotatably received within the anchor body 20 upon advancement of the anchor body 20 over a shaft of the anchor tip 30, the anchor tip 30 being configured to receive the tensionable construct and the flexible material. The anchor tip has a closed aperture or eyelet to receive the flexible material (suture or suture tape) to be attached to bone. The anchor tip 30 may be a metal tip or non-metal tip (e.g., plastic or polymer), and the anchor body 20 may have a cylindrical, screw-like configuration (for example, a cannulated interference screw).

Flexible material 70 can comprise any type of flexible material or suture known in the art, preferably suture tape such as Arthrex FiberTape®, or combination of suture and suture tape, among many others. Flexible material 70 can be configured to be pre-loaded or threaded through eyelet 32 of anchor tip 30. A first limb 72 a and a second limb 72 b pass outside of anchor body 20 and are secured against the bone wall and exterior 26 by friction or interference fit. In an exemplary embodiment, first limb 72 a and second limb 72 b can terminate into a single suture passing limb 74 to simplify passing each of limbs 72 a and 72 b through tissue. In this manner, both limbs 72 a and 72 b can be passed at the same time. After passing limb 74 is passed through tissue, it can be cut and removed, leaving first limb 72 a and second limb 72 b separated and passed through tissue.

In another embodiment, first limb 72 a and second limb 72 b do not terminate into a single passing limb, and are passed through tissue separately. In this embodiment, flexible material 70 may or may not be pre-loaded through eyelet 32 of anchor tip 30. In another embodiment, first limb 72 a and second limb 72 b do not terminate into a single suture passing limb, but both are loaded into a suture passer together and passed together.

FIG. 3 illustrates an exemplary embodiment of anchor tip 30 with tensionable construct 50 preloaded onto anchor tip 30. Tensionable construct 50 comprises a tensioning strand 52, a tensionable loop 54, a splice 55, and fixed loop strands 56 a and 56 b of stand 56 attached to loop 54. Fixed loop strands 56 a and 56 b pass through tensionable loop 54 and can terminate into a single loop strand 56. Loop strand 56 and tensioning strand 52 can then terminate into a single tensioning construct passing limb 58. In another embodiment, loop strands 56 a and 56 b do not terminate into a single loop strand 56, but instead terminate along with tensioning strand 52 into tensioning construct passing limb 58. In this embodiment, three limbs teiminate into one limb at the same place. Tensioning construct passing limb 58 can be passed through tissue and then cut and removed. Loop strands 56 a and 56 b can then be discarded, leaving tensioning strand 52 and tensionable loop 54 passed through the tissue. Multiple tensionable loop strands may be provided attached to loop 54 (for example, passed through the loop 54). Loop 54 is a knotless, tensionable, adjustable, self-cinching loop having an adjustable perimeter.

Tensionable construct 50 can be pre-loaded onto anchor tip 30 by tying static knot 60 on the outside of hole 34. Tensioning strand 52, tensionable loop 54, splice 55, and loop strands 56 a and 56 b pass through cannulated shaft 36 of anchor tip 30 and then through cannulated anchor body 20, exiting fixation device 10 at distal end 24 of anchor body 20. FIG. 4 illustrates loop strands 56 a, 56 b terminating into loop strand 56, and then loop strand 56 and tensioning strand 52 terminating into tensioning construct passing limb 58.

FIGS. 5-18 illustrate various exemplary embodiments 30 a-30 d of anchor tip 30.

FIGS. 5-8 illustrate exemplary embodiment 30 a of anchor tip 30. Anchor tip 30 a can include eyelet 32 a, hole 34 a, and cannulated shaft 36 a. Hole 34 a is positioned at the proximal tip of anchor tip 30 a. Cannulated shaft 36 a can have an outer width 37 a and an inner width 38 a, where inner width 38 a represents how wide the hollow portion of cannulated shaft 36 a is. In an exemplary embodiment, hole 34 a can be wider than the inner width 38 a. In another exemplary embodiment, hole 34 a and inner width 38 a can be approximately the same width. In another exemplary embodiment, hole 34 a can be narrower than inner width 38 a. Additionally, tip body 31 a can be wider than outer width 37 a of cannulated shaft 36 a. Proximal end 33 a of anchor tip 30 a can be wider than, about as wide as, or narrower than, outer width 37 a of cannulated shaft 36 a. The size and shape of eyelet 32 a can be any suitable size and shape. In the exemplary embodiment of FIGS. 5-8, eyelet 32 a has two rounded ends, wherein first rounded end 40 a, located near proximal end 33 a of anchor tip 30 a, is smaller than second rounded end 41 a located near cannulated shaft 36 a.

FIGS. 9-11 illustrate another exemplary embodiment 30 b of anchor tip 30. Anchor tip 30 b can include eyelet 32 b, hole 34 b, and cannulated shaft 36 b. Hole 34 b is positioned at positioned at the proximal tip of anchor tip 30 b. Anchor tip 30 b can further have a second hole 35 b located on the side of anchor tip body 31 b. Cannulated shaft 36 b can have an outer width 37 b and an inner width 38 b, where inner width 38 b represents how wide the hollow portion of cannulated shaft 36 b is. In an exemplary embodiment, hole 34 b can be wider than the inner width 38 b. In another exemplary embodiment, hole 34 b and inner width 38 b can be approximately the same width. In another exemplary embodiment, hole 34 b can be narrower than inner width 38 b. Additionally, tip body 31 b can be wider than outer width 37 b of cannulated shaft 36 b. Proximal end 33 b of anchor tip 30 b can be wider than, about as wide as, or narrower than outer width 37 b of cannulated shaft 36 b. The size and shape of eyelet 32 b can be any suitable size and shape. In the exemplary embodiment of FIGS. 9-11, eyelet 32 b has two rounded ends, wherein first rounded end 40 b, located near proximal end 33 b of anchor tip 30 b, is smaller than second rounded end 41 b located near cannulated shaft 36 b.

FIGS. 12-14 illustrate another example embodiment 30 c of anchor tip 30. Anchor tip 30 c can include eyelets 32 c, hole 34 c, and cannulated shaft 36 c. Hole 34 c is positioned at positioned at the proximal tip of anchor tip 30 c. Cannulated shaft 36 c can have an outer width 37 c and an inner width 38 c, where inner width 38 c represents how wide the hollow portion of cannulated shaft 36 c is. In an exemplary embodiment, hole 34 c can be wider than the inner width 38 c. In another exemplary embodiment, hole 34 c and inner width 38 c can be approximately the same width. In another exemplary embodiment, hole 34 c can be narrower than inner width 38 c. Additionally, tip body 31 c can be wider than outer width 37 c of cannulated shaft 36 c. Proximal end 33 c of anchor tip 30 c can be wider than, about as wide as, or narrower than outer width 37 c of cannulated shaft 36 c. The size and shape of eyelets 32 c can be any suitable size and shape. In the exemplary embodiment of FIGS. 12-14, eyelets 32 c each have an approximately rectangular shape.

FIGS. 15-18 illustrate another exemplary embodiment 30 d of anchor tip 30. Anchor tip 30 d can include eyelet 32 d, hole 34 d, and cannulated shaft 36 d. Hole 34 d can be located on the side of anchor tip body 31 d. Cannulated shaft 36 d can have an outer width 37 d and an inner width 38 d, where inner width 38 d represents how wide the hollow portion of cannulated shaft 36 d is. Tip body 31 d can be wider than outer width 37 d of cannulated shaft 36 d. Proximal end 33 d of anchor tip 30 d can be wider than, about as wide as, or narrower than outer width 37 d of cannulated shaft 36 d. The size and shape of eyelet 32 d can be any suitable size and shape. In the exemplary embodiment of FIGS. 15-18, eyelet 32 d has two rounded ends, wherein first rounded end 40 d, located near proximal end 33 d of anchor tip 30 d, is smaller than second rounded end 41 d located near cannulated shaft 36 d.

FIGS. 19A-D illustrate simplified steps of an exemplary surgical tissue repair 100 with at least one exemplary fixation device described above. The exemplary surgical repair includes a medial row with first and second medial fixation devices 10 a and 10 b, and a lateral row with first and second lateral fixation devices 10 c and 10 d. First and second medial fixation devices 10 a and 10 b can be any embodiment of fixation device 10 described herein, and can comprise anchor body 20, anchor tip 30, tensionable construct 50, and flexible material 70.

First and second lateral fixation devices 10 c and 10 d can be any suitable knotless fixation devices known in the art. For example, first and second lateral fixation devices 10 c and 10 d can be any embodiment of fixation device 10 described herein, or any Arthrex SwiveLock® anchors (as disclosed and described in U.S. Pat. No. 8,012,174 issued Sep. 6, 2011, U.S. Pat. No. 9,005,246 issued Apr. 14, 2015, and US 2013/0296936 published Nov. 7, 2013, the disclosures of all of which are fully incorporated by reference in their entirety herein) or any Arthrex PushLock™ anchors (as described in U.S. Pat. No. 7,329,272 issued Feb. 12, 2008, the disclosure of which is fully incorporated herein by reference), or any combination of these devices.

First and second lateral fixation devices 10 c and 10 d do not have a tensioning construct or suture construct pre-loaded. Instead, first and second lateral fixation devices 10 c and 10 d are secured to the surgical assembly by limbs 72 a, 72 b, 72 c, and 72 d of flexible materials 70 a and 70 b. A first limb 72 a of flexible material 70 a and a first limb 72 c of flexible material 70 b are passed through an eyelet (not pictured) of first lateral fixation device 10 c before the eyelet is loaded into a prepared bone tunnel or hole. Tension can be adjusted if necessary prior to advancing anchor body (not pictured) of lateral fixation device 10 c into the prepared bone tunnel or hole. A second limb 72 b of flexible material 70 a and a second limb 72 d of flexible material 70 b are similarly passed through an eyelet (not pictured) of second lateral fixation device 10 d before the eyelet is loaded into a prepared bone tunnel or hole. Tension can be adjusted if necessary prior to advancing anchor body (not pictured) of lateral fixation device 10 d into the prepared bone tunnel or hole. First and second limbs 72 a and 72 b of flexible material 70 a pass through tensionable loop 54 a and thus can be tensioned by pulling tensioning strand 52 a. Similarly, first and second limbs 72 c and 72 d of flexible material 70 b pass through tensionable loop 54 b and can be tensioned by pulling tensioning strand 52 b. Thus, the final surgical assembly of repair 100 (FIG. 19D) having four fixation devices is secured by flexible materials 70 a and 70 b, while tensioning constructs 50 a and 50 b provide additional tensioning capabilities in addition to providing a backup knotless repair separate from the repair by flexible materials 70 a and 70 b.

Methods of soft tissue repair utilizing the surgical assemblies and devices described above are also disclosed. FIGS. 20-30 illustrate more detailed steps of an exemplary embodiment of a tissue repair method to achieve final repair 200 (FIG. 30).

FIG. 20 illustrates target tissue 90 and bone 99 with two prepared medial bone holes 111 and 112, with first tensionable knotless fixation device 10 a implanted into prepared medial bone hole 111. Fixation device 10 a has an anchor tip and anchor body (not visible since they have been implanted into prepared medial bone hole 111), tensionable construct 50 a, and flexible material 70 a. Tensionable construct has tensioning strand 52 a, tensionable loop 54 a, splice 55 a, and loop strands 56 a and 56 b. Not pictured is the termination of the limbs into a single tensioning construct passing limb. Flexible material 70 a has first limb 72 a and second limb 72 b. Not pictured is the termination of the limbs into a single flexible material passing limb. Tissue 90 may be soft tissue such as rotator cuff, for example.

FIG. 21 illustrates the step of passing tensionable construct 50 a through tissue 90 (for example, tendon, ligament, graft, etc.). In an exemplary embodiment, tensioning strand 52 a and loop strands 56 a and 56 b terminate into a single tensioning construct passing limb 58 a. Tensioning construct passing limb 58 a is loaded into any suitable suture passer known in the art, for example the Arthrex Scorpion™ suture passer. Suture passer 120 is positioned in the desired location on the target tissue and tensioning construct passing limb 58 a is passed through target tissue 90. In embodiments where tensioning strand 52 a and loop strands 56 a and 56 b do not terminate into a single tensioning construct passing limb, then each strand may be passed separately, or loaded into a suture passer capable of passing multiple strands simultaneously.

FIG. 22 illustrates tensioning construct passing limb 58 a passed through target tissue 90. Tensioning construct passing limb 58 a is pulled through target tissue such that tensioning strand 52 a and tensionable loop 54 a also pass through target tissue 90.

FIG. 23 illustrates the step of removing tensioning construct passing limb 58 a from tensionable construct 50 a. Cutting tensioning construct passing limb 58 a leaves three strands: loop strands 56 a, 56 b, and tensioning strand 52 a. Loop strands 56 a and 56 b wrap around tensionable loop 54 a and may be discarded. FIG. 24 illustrates tensioning construct 50 a with tensioning strand 52 a and tensionable loop 54 a passed through tissue 90, and loop strands 56 a and 56 b having been discarded. First and second limbs 72 a and 72 b of flexible material 70 a have not yet been passed through tissue 90.

FIG. 25 illustrates the step of passing flexible material 70 a through tissue 90. In an exemplary embodiment, first and second limbs 72 a and 72 b of flexible material 70 a can terminate into a single flexible material passing limb 74 a. Passing limb 74 a is loaded into any suitable suture passer known in the art, for example the Arthrex Scorpion™ suture passer. Suture passer 120 is positioned at a location on the target tissue adjacent or near where tensioning construct 50 a was passed, and passing limb 74 a is passed through target tissue 90. In embodiments where first and second limbs 72 a and 72 b do not terminate into a passing limb, then each limb may be passed separately, or loaded into a suture passer capable of passing multiple limbs simultaneously.

FIG. 26 illustrates tensioning strand 52 a, tensionable loop 54 a, and first and second limbs 72 a and 72 b all passed through tissue 90. Passing limb 74 a has been cut and removed, leaving first and second limbs 72 a and 72 b separated.

FIG. 27 illustrates the step of retrieving first and second limbs 72 a and 72 b through tensionable loop 54 a. First and second limbs 72 a and 72 b can be retrieved using any retriever known in the art, for example the Arthrex FiberTape® Retriever. After being loaded into retriever 130, limbs 72 a and 72 b are pulled through tensionable loop 54 a.

FIG. 28 illustrates the previously described steps having been repeated and completed for a second medial fixation device 10 b. Second medial fixation device 10 b has an anchor tip and anchor body (not visible since they have been implanted into prepared medial bone hole 112), tensionable construct 50 b, and flexible material 70 b. Tensionable construct has tensioning strand 52 b, tensionable loop 54 b, splice 55 b, and loop strands (not pictured since they have already been discarded). Flexible material 70 b has first limb 72 c and second limb 72 d.

Once first and second medial fixation devices 10 a and 10 b have been implanted, and tensioning strands 52 a and 52 b, tensionable loops 54 a and 54 b, splices 55 a and 55 b, and limbs 72 a, 72 b, 72 c, and 72 d have been passed through tissue 90, lateral bone holes can be prepared for first and second lateral fixation devices 10 c and 10 d. Lateral fixation devices 10 c and 10 d can be any suitable fixation devices, for example any embodiment of fixation device 10 described herein, or any Arthrex SwiveLock® anchors (as disclosed and described, for example, in U.S. Pat. No. 8,012,174 issued Sep. 6, 2011, U.S. Pat. No. 9,005,246 issued Apr. 14, 2015, and US 2013/0296936 published Nov. 7, 2013, the disclosures of all of which are fully incorporated by reference in their entirety herein), or any Arthrex PushLock™ anchors (as described in U.S. Pat. No. 7,329,272 issued Feb. 12, 2008, the disclosure of which is fully incorporated herein by reference), or any screw-in or push-in type anchors, or any combination of these devices.

First and second lateral fixation devices 10 c and 10 d do not have a tensionable construct or flexible material (suture tape) pre-loaded. Instead, first and second lateral fixation devices 10 c and 10 d are secured to the surgical assembly by limbs 72 a, 72 b, 72 c, and 72 d of flexible material 70 a and 70 b. First limb 72 a of flexible material 70 a and a first limb 72 c of flexible material 70 b are passed through an eyelet (not pictured) of first lateral fixation device 10 c before the eyelet is loaded into a prepared bone hole. Tension can be adjusted if necessary prior to advancing anchor body (not pictured) of lateral fixation device 10 c into the prepared bone hole. Second limb 72 b of flexible material 70 a and a second limb 72 d of flexible material 70 b are similarly passed through an eyelet (not pictured) of the second lateral fixation device 10 d before the eyelet is loaded into a prepared bone hole. Tension can be adjusted if necessary prior to advancing anchor body (not pictured) of lateral fixation device 10 d into the prepared bone hole.

After first and second lateral fixation devices 10 c and 10 d have been fixated/inserted/implanted, the resulting surgical assembly is shown in FIG. 28. Any remainder of limbs 72 a, 72 b, 72 c, and 72 d extending out from lateral fixation devices 10 c and 10 d may be cut off using any suitable suture cutter, for example the Arthrex FiberWire® cutter. FIG. 28 also illustrates the step of pulling tensioning strand 52 a to tighten tensionable loop 54 a in order to apply tension to first and second limbs 72 a and 72 b.

FIG. 29 illustrates the step of pulling tensioning strand 52 b to tighten tensionable loop 54 b in order to apply tension to first and second limbs 72 c and 72 d of suture construct 70 b.

FIG. 30 illustrates the final surgical repair 200. Tensionable loops 54 a and 54 b have been tensioned, and tensioning strands 52 a and 52 b have been cut to remove them from the final assembly. Tensioning strands 52 a and 52 b can be cut using any suitable suture cutter, for example the Arthrex FiberWire® cutter.

An exemplary method of tissue repair comprises inter alia the steps of: (i) inserting into bone a surgical assembly comprising a fixation device; a tensionable construct pre-loaded on the fixation device, the tensionable construct including a tensioning strand, a knotless, adjustable, self-cinching, tensionable loop having an adjustable perimeter, and a splice adjacent the loop; and a flexible material (for example, suture tape) attached to the fixation device; and (ii) passing the tensionable construct and limbs of the flexible material around or through tissue to be fixated (or reattached) to bone, so that the tensionable loop is positioned over the tissue, and then passing limbs of the flexible material through the tensionable loop. The method may further comprise the step of securing the limbs of the flexible material into bone. The limbs may be secured with at least another fixation device that is inserted into bone. The method may further comprise the step of pulling on the tensioning strand to appropriate tissue to bone. The tissue may be soft tissue such as tendon, ligament, or graft.

Another exemplary method of soft tissue repair comprises inter alia the steps of: (i) inserting into bone a surgical assembly comprising a fixation device; a tensionable construct pre-loaded on the fixation device, the tensionable construct including a tensioning strand, a knotless, adjustable, self-cinching, tensionable loop having an adjustable perimeter, and a splice adjacent the loop; and a flexible material (for example, suture tape) attached to the fixation device; (ii) passing the tensionable construct and limbs of the flexible material around or through tissue to be fixated (or reattached) to bone so that the tensionable loop is positioned above and over the soft tissue, and above and over the bone; (iii) subsequently, passing limbs of the flexible material through the tensionable loop; and (iv) passing the limbs of the flexible material over the tissue and securing the limbs with additional fixation devices into bone, to form a mattress stich repair.

Another exemplary method of soft tissue repair comprises inter alia the steps of: (i) inserting into bone a plurality of surgical assemblies, each surgical assembly comprising a fixation device; a tensionable construct pre-loaded on the fixation device, the tensionable construct including a tensioning strand, a knotless, adjustable, self-cinching, closed, tensionable loop having an adjustable perimeter, and a splice adjacent the loop; and a flexible material (for example, suture or suture tape) attached to the fixation device; (ii) passing the tensionable construct and limbs of the flexible material—of each surgical assembly—around or through tissue to be fixated (or reattached) to bone, so that the tensionable loop of each surgical assembly is positioned over and above the soft tissue, and over and above the bone; (iii) subsequently, passing limbs of the flexible material of each surgical assembly through the corresponding tensionable loop; and (iv) passing the limbs of each surgical assembly over the tissue, and securing the limbs with a plurality of fixation devices into bone, to form a mattress stich repair.

The flexible strands and materials described above may be formed of strands of high strength suture material with surgically-useful qualities, including knot tie down characteristics and handling, such as Arthrex FiberWire® suture disclosed in U.S. Pat. No. 6,716,234, the disclosure of which is incorporated by reference in its entirety herein. FiberWire® suture is formed of an advanced, high-strength fiber material, namely ultrahigh molecular weight polyethylene (UHMWPE), sold under the tradenames Spectra (Honeywell) and Dyneema (DSM) fibers, braided with at least one other fiber, natural or synthetic, to form lengths of suture material. The flexible strand may be a high-strength suture, such as an ultrahigh molecular weight polyethylene (UHMWPE) suture which is the preferred material as this material allows easy splicing.

The suture constructs may be formed of optional colored strands, such as black or blue, to assist surgeons in distinguishing between suture lengths with the trace and suture lengths without the trace. Preferably, each of the limbs may be provided in different colors to assist surgeons in retrieving one limb from each of the knotless fixation devices and then loading them through another knotless fixation device, during the formation of the criss-cross suturing pattern.

Suture constructs may be coated (partially or totally) with wax (beeswax, petroleum wax, polyethylene wax, or others), silicone, silicone rubbers, PTFE (Teflon, Hostaflon, or others), PBA (polybutylate acid), ethyl cellulose (Filodel) or other coatings, to improve lubricity of the suture or tape, knot security, pliability, handleability, or abrasion resistance, for example.

Suture constructs may also contain a bioabsorbable material, such as PLLA or one of the other polylactides, for example, and/or may be formed of twisted fibers having strands of a contrasting color added to the braided threads, to make the suture more visible during surgical procedures. The colored strands can be dyed filaments or strands, for example.

The surgical assembly and methods of the present invention have applicability to tissue repairs such as rotator cuff repair, Achilles tendon repair, patellar tendon repair, knee repairs such as ACL and/or PCL reconstruction, hip and shoulder reconstruction procedures, and applications involving repairing soft tissue to bone.

FIG. 31A illustrates a tensionable fixation device 102 with a pre-loaded tensionable loop (pre-looped tensionable fixation devices), and FIG. 31B illustrates another type of tensionable fixation device without a pre-loaded tensionable loop (non-pre-looped tensionable fixation device) 202 used in methods of tissue repair illustrated in FIGS. 32A-32D, FIGS. 33A-33C, and FIGS. 34A and 34B, in accordance with various exemplary embodiments as disclosed. The methods of FIGS. 32A-32D, 33A-33C, and 34A and 34B are more secure than conventional knot repairs, are faster than conventional repairs thus saving time and money in the OR, eliminate the potential of knots impinging against adjacent structures and causing irritation or damage, and eliminate any knot failures of the repair.

As seen in FIG. 31A, the pre-looped tensionable suture anchor fixation device 102 that preferably includes an anchor body 120 that receives an anchor tip 130. The anchor tip 130 preferably includes an eyelet body 132 having an eyelet 160 sized to receive a flexible member 170 (FIG. 33A). The tensionable pre-looped suture anchor fixation device 102 supports a tensionable construct 150 in a shaft 136 of the anchor body 120. The tensionable pre-looped suture 150 may include a flexible strand 152 and a pre-looped tensionable loop 154 spliced through a flexible strand 152. The flexible strand 152 may have a knotted end 156 that engages the eyelet body 132 of the anchor tip 130 to prevent the strand 152 from pulling through the anchor body 120, and a free end 158 opposite the knotted end 156. Both the free end 158 and at least a portion of the tensionable loop 154 extend outside of the fixation device 102.

As seen in FIG. 31B, the non-pre-looped tensionable suture anchor fixation device 202 may include an anchor body 220 and an anchor tip 230 (having an anchor tip body 232 and knotted end 256), similar to pre-looped tensionable fixation device 102. The anchor tip 230 may include an eyelet body 232 having an eyelet 160 sized to receive a flexible member 172 (FIG. 33A). The non-pre-looped tensionable suture anchor fixation device 202 supports a non-pre-looped tensionable construct 250 in a shaft 236 within the anchor body 220. The -non-pre-looped tensionable suture construct 250 may include a flexible strand 252 that has a knotted end 256 engaging the eyelet body 232 of the anchor tip 230, and an opposite free end 258. The flexible strand 252 is preferably coupled with a passer device 260. The passer device 260 may be any known suture shuttling or puller that includes an eyelet 262 and a tail end 264 opposite the eyelet 262. The passer device 260 may be threaded through a splice in the flexible strand 252. The free end 258 of the flexible strand 252 and both the eyelet 262 and tail end 264 of the passer device 260 are outside of the anchor body 220.

FIGS. 32A-32D illustrate an exemplary method of tissue repair using the pre-looped and non-pre-looped tensionable fixation devices 102 and 202 of FIG. 31A and 31B, respectively. As seen in FIG. 32A, the pre-looped and non-pre-looped tensionable fixation devices 102 and 202 are preferably pre-loaded with constructs 150 and 250, respectively, and are anchored in bone 99, preferably in a medial row. The tensionable construct 150 of the pre-looped tensionable fixation device 102 is passed through a target area in the tissue 90 (soft tissue layer). The construct 250 of the non-pre-looped tensionable fixation device 202 is passed through another target area in the tissue 90. Once passed through the tissue 90, the pre-looped tensionable loop 154 (or a portion thereof) and the free end 158 of the pre-looped tensionable construct 150, and the free end 258, the passer device eyelet 262 and tail end 264 of the non-pre-looped tensionable construct 250, are above or outside of the tissue 90. A cannula 300 may be optionally provided to facilitate management of the constructs 150 and 250.

Once the constructs 150 and 250 are passed through the tissue 90, interlocking loops are formed by first threading the free end 258 of the non-pre-looped tensionable construct 250 through the tensionable loop 154 of the tensionable pre-threaded construct 150 and then threading the free end 258 back through the eyelet 262 of the passer device 260 of the non-pre-threaded tensionable construct 250, as seen in FIG. 32B. The tail end 264 of the passer device 260 can then be pulled away from the repair to thread the free end 258 of the strand 252 through itself (as shown by arrows in FIG. 32B), thereby forming two interlocking loops, as seen in FIG. 32C. Those loops may then be tightened by pulling on the free ends 158 and 258, as seen in FIG. 32C, thereby providing a secure suture on the tissue repair.

FIG. 32D illustrates an optional step of further securing the free ends 158 and 258 of the constructs 120 and 250, respectively, once tightened on the repair, by employing additional fixation devices 302 to fix the free ends 158 and 258 to bone 99. The additional fixation devices 302 may be any known fixation device, such as SwivelLock C suture anchors. Cinch-loop sutures (90) may be placed and fixed to the lateral row anchor to eliminate dog ears. The fixation devices 302 are preferably arranged in a lateral row so that the free ends 158 and 258 of the constructs 120 and 250 may cross one another and be secured via fixation devices 302 to form a suture bridge that links the medial row of suture anchors to the lateral row of suture anchors.

FIGS. 33A-33D illustrate another exemplary method of tissue repair using the tensionable and non-tensionable fixation devices 102 and 202 of FIG. 31 and incorporating flexible materials 170 and 172. As seen in FIG. 33A, once the fixation devices 102 and 202 are anchored to bone 99 and the constructs 150 and 250 are passed through the tissue 90, the limbs 170 a and 170 b of flexible material 170 may be passed through the tissue 90 proximal to the tensionable construct 150, and the limbs 172 a and 172 b of flexible material 172 may be passed through the tissue 90 proximal to the non-tensionable construct 250. As seen in FIG. 33B, two interlocking loops of the constructs 150 and 250 are formed in the same manner as disclosed above regarding the embodiment of FIGS. 32A-32D. The limbs 170 a, 170 b of flexible material 170 and limbs 172 a, 172 b of flexible material 172 may be passed through the tissue either before or after the interlocking loops of the constructs 150 and 250 are formed and are preferably passed through the tissue before the interlocking loops of the constructs 150 and 250 are fully tensioned or tightened. Once the interlocking loops of the constructs 150 and 250 are fully tensioned to form a load sharing rip-stop on the repair, the limbs 170 a, 170 b of flexible material 170 and limbs 172 a, 172 b of flexible material 172 may be pulled over the rip-stop of constructs 150 and 250 to be secured to additional fixation devices 302 anchored in bone 99. In this embodiment, the flexible materials 170 and 172, such as suture tape, act as the primary securing sutures for the tissue repair. The additional fixation devices 302 may be arranged in a lateral row in bone 99 and the limbs 170 a, 170 b of flexible material 170 and limbs 172 a, 172 b of flexible material 172 may cross one another to form a bridge to compress the underlying tissue against the bone. For example, the limb 170 a and the limb 172 a may be secured to one of the additional fixation devices 302 and the limb 170 b and the limb 172 b may be secured to the other of the additional fixation devices 302, as seen in FIG. 33C.

FIGS. 34A and 34B illustrate yet another exemplary method of tissue repair using two tensionable fixation devices 150. Unlike the embodiments of FIGS. 32A-32D and 33A-33C, the embodiment of FIGS. 34A and 34B do employ a tensionable fixation device. As seen in FIG. 34A, two of tensionable fixation devices 102 are preloaded with constructs 150 and anchored in bone 99 and the constructs 150 are passed through the tissue 90. The tensionable loops 154 of each construct 150 are passed separately though two different target areas in the tissue 90 and then tied together with a knotted segment 304. A cannula 300 may be used to facilitate management of the constructs 150 outside of the tissue 90. Once the loops 154 are tied together, they are brought down or over the tissue 90 by pulling on the free ends 158 and 258 of the tensionable constructs 150, as seen in FIG. 34B. The knotted segment 304 preferably remains in an open loop, thereby facilitating sliding of the interlinked loops 154 on each other as the loops are tensioned.

FIG. 35 illustrates a driver and anchor assembly construct. A thumb pad 302 is located below the handle 304 of the assembly construct. The assembly construct includes a reverse threaded sleeve 300, which serves to drive an anchor body 120, such as a screw-in anchor body (such as a SwiveLock anchor), into a solid surface, such as into a bone. Located on the eyelet body 180 is a hole 156, through which a knotted suture 256 will exit. The knotted suture 256 functions to fix a distal end of a tensionable suture loop to the anchor body 120. A tensionable suture loop as part of the assembly construct may be provided by including a pre-threaded tensionable suture loop, so as to provide a construct assembly having a “pre-looped” tensionable loop. Alternatively, a tensionable loop that is not pre-threaded may be included with the assembly construct, so as to provide a “non-pre-looped” tensionable loop version of the assembly construct. In the non-pre-looped tensionable loop construct assembly configuration, the tensionable loop will be formed after the anchor body 120 has been inserted into a surface, such as inserted into bone. The driver and anchor body assembly would take on the same general appearance in both the pre-looped and non-pre-looped tensionable loop construct assembly. A knotted suture end 256 exiting a hole 156 in the side of the eyelet body 180 of the tip 190, serves to fix a distal strand of a tensionable loop (either pre-looped or non-pre-looped tensionable loop construct), to the anchor body 120. An eyelet 160 is provided within the eyelet body 180 of the tip 190.

FIG. 36A illustrates a pre-looped tensionable loop assembly 150 and FIG. 36B illustrates a non-pre-looped tensionable loop assembly 250. The pre-looped tensionable loop assembly 150 includes a tensionable loop 154 that has been pre-threaded through a splice region 155. A knotted suture end 156 at the eyelet body 180 serves to fix the distal strand of the tensionable loop 154 within a suture anchor.

FIG. 36B illustrates the non-pre-looped tensionable loop assembly 250 that includes a looped end 262 of a passing strand 210 (passing strand may be a FiberLink passer strand or a Nitinol wire passer strand). The free end 264 of the passing strand 300 and the main fixation suture limb 258 are provided as part of the non-pre-looped tensionable loop assembly. The main fixation suture limb 258 will be threaded through a splice region 255 of the suture after passing the suture limb 258 through the soft tissue that is to be secured. A knotted suture end 256 at the eyelet body 180 serves to fix a distal end of the tensionable loop once formed

FIG. 37A illustrates the suture anchor and tensionable loop (pre-looped tensionable loop version) construct configuration after the suture anchor 150 has been inserted into a surface, such as into a bone. FIG. 37B presents the eyelet body 130 that includes an eyelet 132, through which a suture limb 170 is passed. Also depicted is the knotted suture end 156 present on the suture body 130.

FIG. 37C illustrates the suture anchor and tensionable loop (non-pre-looped tensionable loop version) construct configuration 250 after the suture anchor 220 has been inserted into a surface, such as into a bone. The main fixation suture 258 will be threaded through the splice region 255 of the suture 252, after the main fixation suture is passed through or around an adjacent or surrounding penetrable material, such as through or around a soft tissue. The free passing end 264 of the passing strand is shown extending out of the suture anchor shaft 350 of the suture anchor 220. The looped end 262 of the passing strand is also shown extending out of the suture anchor shaft 350 of the suture anchor 220. The passing strand may be of a FiberLink passer material or a nitinol wire passer material. An eyelet 232 is provided at a tip 190 provided as part of the construct configuration, and includes an eyelet body 230. Located on the eyelet body 230 is a knotted suture end 256. FIG. 37D—illustrates a detailed view of the tip 190. The tip 190 is shown to include an eyelet body 230 and an eyelet 232, through which a suture 172 may be passed. A knotted suture end 256 is shown at the eyelet body 230. The knotted suture end 256 of the passing suture strand serves to fix the distal end of the tensionable loop, and to maintain a continued tension between the suture and suture anchor after the suture anchor is implanted. This continued tension serves to enhance the self-locking mechanism at the suture splice 255.

A surgical kit is disclosed that may include one or more of the fixation devices 102 and 202 preloaded with the tensionable pre-looped and tensionable non-pre-looped constructs 150 and 152, respectively. One or more of the additional fixation devices 302 may also be provided with the kit along with the optional cannula 300.

While particular embodiments have been chosen to illustrate the invention, it will be understood by those skilled in the art that various changes and modifications can be made therein without departing from the scope of the invention as defined in the appended claims. 

What is claimed is:
 1. A method of knotless tissue repair, comprising the steps of: providing a first fixation device with a preloaded tensionable construct; providing a second fixation device with a non-pre-looped tensionable construct; anchoring the first and second fixation devices in bone such that the first and second fixation devices are arranged in a medial row; passing the preloaded tensionable construct of the first fixation device and the non-pre-looped tensionable construct of the second fixation device through tissue; threading a free end of a flexible strand of the non-pre-looped tensionable construct through a tensionable loop of the pre-looped tensionable construct and then subsequently threading the free end of the non-pre-looped tensionable construct through an eyelet of a passing device coupled with the flexible strand of the non-pre-looped tensionable construct; and pulling on a tail end of the passing device opposite the eyelet thereof to thread the free end of the flexible strand of the first fixation device through a splice in itself, thereby forming two interlocking loops outside of the tissue.
 2. The method of claim 1, further comprising the step of tightening the two interlocking loops by pulling on a free end of the pre-looped tensionable construct and the free end of the non-pre-looped tensionable construct.
 3. The method of claim 2, further comprising the step of sequentially pulling on the free ends of the tensionable and non-tensionable constructs to tighten the two interlocking loops.
 4. The method of claim 3, further comprising the step of securing the free ends of the pre-looped tensionable and non-pre-looped tensionable constructs in bone with third and fourth fixation devices, respectively.
 5. The method of claim 4, further comprising the steps of: arranging the third and fourth fixation devices in a lateral row; and coupling the free ends of the pre-looped tensionable and non-pre-looped tensionable constructs to the third and fourth fixation devices to form a bridge.
 6. The method of claim 1, further comprising the steps of: Prethreading the distal eyelets of the first and second fixation devices with first and second flexible materials, respectively, each of the first and second flexible materials has first and second limbs; and passing the first and second limbs of the first and second flexible materials through the tissue proximal to the pre-looped tensionable and non-pre-looped tensionable constructs, respectively.
 7. The method of claim 6, wherein the step of prethreading the distal eyelets of the first and second fixation devices with first and second flexible materials includes threading the first and second flexible materials through eyelets of the first and second fixation devices, respectively.
 8. The method of claim 6, further comprising the step of, after passing the first and second limbs of the first and second flexible materials through the tissue, tightening the two interlocking loops by pulling on a free end of the pre-looped tensionable construct and the free end of the non-pre-looped tensionable construct.
 9. The method of claim 8, further comprising the step of securing the first and second ends of the first and second flexible material to bone with third and fourth fixation devices.
 10. The method of claim 9, further comprising the steps of: arranging the third and fourth fixation devices in a lateral row; and coupling the first limb of the first flexible material and the first limb of the second flexible material to the third fixation device and coupling the second limb of the first flexible material and the second limb of the second flexible material to the fourth fixation device to form a bridge.
 11. The method of claim 1, further comprising the step of passing the pre-looped tensionable and non-pre-looped tensionable constructs through a cannula after passing the pre-looped tensionable and non-pre-looped tensionable constructs through the tissue to facilitate management of the constructs outside of the tissue.
 12. A method of knotless tissue repair, comprising the steps of: providing first and second fixation devices each preloaded with a pre-looped tensionable construct, each pre-looped tensionable construct including a flexible strand having a knotted end coupled to the first and second fixation devices, respectively, a free end opposite the knotted end, and a tensionable loop; anchoring the first and second fixation devices in a first rigid material; passing the tensionable constructs of the first and second fixation devices through a second non-rigid material; and tying the tensionable loops of the first and second fixation devices together outside of the second non-rigid material after passing the tensionable constructs through the second non-rigid material, thereby forming two loops interlinked by a knotted segment.
 13. The method of claim 12, further comprising the step of tightening the tensionable constructs of the first and second fixation devices by pulling on the free ends of the tensionable constructs.
 14. The method of claim 12, further comprising the step of passing the tensionable constructs through a cannula after passing the tensionable constructs through second non-rigid material. 